Abstract Background: Sub-Saharan Africa and Sierra Leone bear one of the world’s highest maternal mortality rates. In rural Sierra Leone, 19% of births occur at home, contributing to high maternal mortality ratios. Objective: To identify characteristics and reasons for home births among women in the rural Mathonkara Catchment area, Sierra Leone. Design: Cross-sectional study. Setting: 23 rural villages in the Mathonkara Catchment Area, Sierra Leone. Population: Women of childbearing age, who gave birth, miscarried or had an abortion between February 1, 2022, and January 31, 2023. Methods: A structured questionnaire assessed birthplaces, demographic characteristics, maternal health indicators, care seeking behaviors and previous experiences of care at health facilities. Main Outcome Measures: Prevalence of home births and associated determinants. Results: 555 women were included. The prevalence of home births stood at 26.67%. Characteristics associated with home births included feeling healthcare workers did not care about your life (AOR=19.11; 95% CI:1.57-799.61), living >1 km from a health facility (AOR=7.15; 95% CI:3.12-16.51), ≤3 antenatal care visits (AOR=4.84; 95% CI:2.37-10.14) and previous home births (AOR=4.17; 95% CI:2.42-7.30). Barriers included nighttime labor, transportation costs and availability and healthcare service costs. Conclusion: The factors influencing home births in rural Sierra Leone are multifaceted. To improve maternal outcomes, it is crucial to address the challenges that impede facility-based births, including quality of care and respectful care at health facilities, distance, economic costs of reaching facilities and transportation challenges such as quality of roads and availability of transportation. Keywords: Maternal Health, Sierra Leone, Home Birth, Antenatal care, Tonkolili

Objective: This study identified the prevalence of miscarriages and perinatal deaths from a community perspective. Design: A population-based, cross-sectional household study. Setting: Sierra Leone (West-Africa) from 2019-2020 Population: Women of reproductive age Methods: Seventy-five randomized clusters were selected, 25 households in each cluster and two random participants from each household. Female participants between 12 and 50 years of age were interviewed about family planning methods and obstetrical history. Main outcome measures: miscarriage and perinatal death Results: A total of 914 women of reproductive age were included. Family planning methods were used by 29% of the women. In total, 2,160 life-time pregnancies were recalled of which 104 (5%, 95% CI 4-6%) resulted in an early pregnancy loss. Eighty-three (80%) were reported as spontaneous abortion, 17% (18) were intentional abortions, of which 9 were induced with medication outside the hospital. The stillbirth rate was 18.5 (95% CI 9-31) per 1000 births and the perinatal mortality rate was 38,4 (95% CI 24-54) per 1000 births calculated over a 5-year period. Conclusion: This study confirms that the perinatal death rate in Sierra Leone exceeds the global average. The miscarriages both spontaneous and intentional, are likely to be underreported. Medical attention should be placed to treat and investigate the causes of miscarriages and perinatal deaths. Improving the use of family planning is needed to decrease the hidden burden of intentional abortions. Funding: Norwegian University of Science and Technology (NTNU) and University of Amsterdam’s Center of Tropical Medicine and Travel Medicine.